MEDICARE: MDA OPTICAL LAB CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1578815320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MDA OPTICAL LAB CORPORATION

Provider Business Mailing Address
First Line	:	1797 STILLWELL AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-1037
Country	:	US
Telephone Number	:	718-436-1848
Fax Number	:

Provider Business Practice Location Address
First Line	:	119 CHURCH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11218-3917
Country	:	US
Telephone Number	:	718-436-1848
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID LITOVSKY
Credential	:
Telephone Number	:	718-436-1848

Provider Enumeration Date	:	10/03/2012
Last Update Date	:	10/03/2012

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